You are an anesthesiologist in a trauma operating room. Your patient is a 23-year-old woman (55 kg) with a complicated left femur fracture. She was brought to the emergency department, where they did initial laboratory testing and ordered 4 units of RBC to be crossmatched, due to the expected higher blood loss. The patient was then transported to the operating room for surgical stabilization of the fracture.
As EXACYL® (tranexamic acid) has not yet been administered, we are now administering 1g. Blood loss during the operation is around 700 ml and still increasing. The surgeon discovered a tumour at the fracture site, which he resected and continues with osteosynthesis. He begins to introduce the intramedullary nails and notices a major bleed. Another 200 ml of blood is quickly sucked into the aspirator. You can see these vital functions on the monitor.
What will be the next step?
On a preoperative X-ray of the thigh, the radiologist described a focal lesion with decreased bone density on the distal part of the femoral shaft of uncertain origin extending into the fracture line.
Laboratory values shown are from blood tests done at the emergency room.
Used abbreviations: ED - Emergency department PoC - Point-of-Care RBC - red blood cells HGB - haemoglobin FBG - fibrinogen DOAC – direct oral anticoagualnts LMWH – low molecular weight heparin
Tranexamic acid (EXACYL®) blocks the binding of plasmin to fibrin, thereby partially inhibiting fibrinolysis. It is used to prevent and treat major bleeding, especially in pre-hospital care. Possible side effects include muscle cramps and an increased risk of thromboembolic disease.
Etamsylate (DICYNONE®) increases the ability of platelets to form blood clots. The effect is a reduced tendency to bleed from small blood vessels and capillaries. Due to its mechanism of action and delayed onset, the product is not indicated to stop major arterial or venous bleeding.
Thromboelastometry is a method that measures the viscoelastic properties of the clot in the process of its formation and lysis. It provides us with this information in real-time and thus allows us to make a comprehensive assessment of the state of coagulation. The change in the mechanical properties of the blood in the cuvette is detected and recorded using a characteristic curve on the computer screen, which we will describe in the following section. Unlike conventional coagulation tests, whole blood is used in this test, and thus the role of blood cell components in the clotting process - mainly platelets - is taken into account. A known limitation of this method is the inability to assess the effects of some drugs such as TXA2 inhibitors (eg. acetylsalicylic acid) and DOAC (direct oral anticoagulants) on the bleeding condition.
